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SAN JOAQUIN LOCAL HEALTH DISTRICT E <br /> FOR OFFICE USE: �\\ 1601 E. Hazelton Ave. , Skotkton, Calif. <br /> Telephone:, (209) 466-6781 <br /> LICATION FOR WELL CONSTRUCTION.•OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES 1 YEAR-'FROMcDATE ISSUED Date Issued 7-t . `1 L <br /> • (Complete In=Triplicate) <br /> Application 'is-hereby-.made,to the,:San�-Joaquin Local Health District -for a permit to construct <br /> and/or install the work herein described. This application is made 'in compliance with San Joaquin <br /> County-Ordinance„No 18'62 :and ,the'Rulediand:,Regulations of the San Joaquin Local Health District. � <br /> t Z. <br /> JOB ADDRESS/LOCATION Q Z. <br /> S,04,Y_4 o=� Lld' CENSUS TRACT` <br /> Owner r s Name ` `'.�^ .~ aj o Phone ' 4" <br /> Address City n �, f <br /> Contractor's Name u; License # L&?-)2g-Phone ' <br /> TYPE OF WORK (Check) :, NEW WELL/ / DEEPEN '/ / RECONDITION / / DESTRUCTION /7 <br /> AL <br /> PUMP INSTLATION/ / PUMP: REPAIR j&/--PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK'% SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial ;-- Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public .Driven Gauge of Casing <br /> Irrigation -- <br /> $ - Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout <br /> Other Other Information ' <br /> PUMP INSTALLATION: Contractor" `_. .-" <br /> Type of Pump T �t H.P. <br /> .. 4 <br /> PUMP REPLACEMENT: / /, State Work Done <br /> PUMP REPAIR: State Wo <br /> / / rk�Done <br /> ,DESTRUCTION OF WELL: Well Diameter-- ;. Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and -the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the we-1l-and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. . <br /> SIGNED UyJ ;; <br /> TITLE <br /> 001 <br /> (DRAW PLOT PLAN ON REVERSE SID <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I n i <br /> APPLICATION ACCEPTED BY DATE � _11;L <br /> ADDITIONAL COMMENTS: <br /> PHAS II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY _ DATE INSPECTION BY DATE �- <br /> CALL FOR A GR UT, INSPECTION PRIOR TO GROUTING AND FINAL INSPECTIO <br /> E H 1426 #. -'•""- 4/72 1M <br />